Will soft drink sugar taxes solve the obesity and diabetes epidemics?

Recently, the ‘sugar tax’ on fizzy drinks came into force in the UK. Might it signal the end of our love affair with all things sweet? The Telegraph travels to Mexico, where cola consumption per capita – and obesity rates – are among the highest in the world. Photographs by Jordi Ruiz Cirera.ByHenry Bodkin25 APRIL 2018 • 11:43AM

oises Sanchez has intelligent, humorous eyes, but as he takes out his phone and brings up a picture of Merari, his eight-year-old daughter, they are pinched with sadness. ‘As you can tell, she’s not thin,’ he says. ‘We’re taking her to dance classes and have given her an eating schedule to control her diet. The other kids have started to bully her – I tell her to try not to get sad.’

Moises, a lawyer specialising in corporate fraud, is a doting father but an uncertain role model. He himself weighs 26 stone and is addicted to sugary food and drink. In a sombre apartment above a garage in the modest Mexico City suburb of Tlacotal Ramos Millán, he tells a late-night meeting of Tragones Anónimos (roughly translated as ‘Guzzlers Anonymous’) about the times when things get really bad. He’ll quite often drink four litres of Coca-Cola in a day. ‘Technically, it’s sugar that triggers satisfaction because it is the substance processed quickest by the body,’ he explains with grim animation. ‘I look for immediate satisfaction, with carbohydrates in their purest form. Give me carbohydrates – they’re delicious!’

If it isn’t Coke, then it’s gummy bears; if not fast food, then extra tacos. In February, unable to control his diet, Moises declared a ‘crisis’ and went to live at Tragones Anónimos, where his eating switched in favour of vegetables (cabbage is a staple) and non-processed food, combined with regular weighings and a strict daily calorie limit. There are no fizzy drinks on the premises.

The great fear, says Moises, is type 2 diabetes, which afflicted his parents, costing his father both legs. Obesity has taken a large enough toll as it is. His marriage failed – ‘I didn’t feel attractive… we had trouble in the bedroom’ – meanwhile, at work Moises believes he has lost business because his appearance calls his professionalism into doubt. ‘They think, “If he cannot control his eating, he won’t be able to control my case and I will end up in jail”.’

Moises is an extreme case, but his story is becoming less and less unusual in a society enjoying relative prosperity and whose traditional diet is under siege from foreign processed food and, above all, sugary drinks; a country that elected a former top Coca-Cola executive as its president, and in whose schools the company paints vast murals boasting of the drink’s benefits.

Established 35 years ago along similar lines to Alcoholics Anonymous, the self-funded Tragones movement has grown in recent years as Mexico ascended the world obesity ranking – it was fifth last year. Like Moises, those who join – office workers, stay-at-home mums, IT engineers – tend to have acute problems. But in one crucial respect, he and his compadres are ahead of their fellow Mexicans: at least they accept they have a problem.

They are in the minority. A recent survey established that 80 per cent of the Mexican population is aware of the dangers associated with sugary drinks. Nevertheless, Mexico is the second thirstiest consumer of such products in world, with people deriving, on average, around 70 per cent of their total added sugar intake from fizzy drinks. According to Dr Pablo Kuri-Morales, Mexico’s undersecretary of prevention and health promotion, most Mexicans more or less understand what constitutes a bad diet, they just don’t believe the risk applies to them personally. Approximately 40 per cent of Mexicans told they may have diabetes fail to turn up for a further consultation.

Speaking in his elegant government office near Bosque de Chapultepec, the Mexico City showpiece park where joggers are conspicuous by their absence, Kuri-Morales sums up the problem. ‘Most adults perceive themselves as healthy,’ he says. ‘They don’t want to change their diets: they don’t care.’

The same self-delusion appears to take place in Britain. Research by the Office for National Statistics in 2017 found that, on average, people in the UK under-report the number of calories they consume per day by more than a third. Jack Winkler, emeritus professor of nutrition policy at London Metropolitan University, says, ‘The majority of the population is not interested in healthy eating. They’ve got other things on their minds. They know what’s right but they’re not interested in acting on it for a whole host of good and bad reasons.’ While neither expert could be accused of despair, they share the same despondency.

As well they might. After all, public health and nutrition bodies have spent decades advocating education as the best practical means of fighting unhealthy living – yet worldwide obesity has almost tripled since 1975. With nearly two billion adults found to be overweight as of 2016, of which 650 million were obese, the failure of leaving healthy eating to citizens’ good judgement is clear.

Last October, NHS data revealed the highest-ever proportion of obese English children leaving primary school – one in five – while 63 per cent of British adults are classed as overweight (BMI 25-29.9) or obese (BMI 30-plus). An abundance of sugar in the diet is also suspected to be behind the rocketing total of under-18s needing teeth removed in hospital: 170 a day.

With more people surviving the illnesses that used to kill them, enabling long and expensive retirements, health systems do not have the cash to spare on what Simon Stevens, chief executive of NHS England, euphemistically refers to as ‘modifiable’ risk factors. Or, in plain English, self-inflicted wounds. Governments around the world are fed up; they can no longer afford to wait for their citizens to mimic Moises and admit, ‘I have a problem’.

Yesterday, the manifestation of the UK Government’s impatience, the Soft Drinks Industry Levy, came into force. Even before its announcement by George Osborne in the 2016 budget, the legislation was ubiquitously dubbed a ‘sugar tax’.

That, however, has mandarins gnashing their teeth, as the measure is not a levy on sugar per se, or even on all high-sugar drinks – fruit juice and milkshakes are exempt – but specifically on sodas or fizzy drinks: certain brands of Coca-Cola, Pepsi, Irn Bru etc. Importers and manufacturers are now subject to a multi-tier regime, paying 18p per litre if the drink has five grams or more of sugar per 100ml, and 24p per litre if it contains eight grams or more. In bringing in the levy, Britain joins 30 countries where a tax has or will be introduced, including France, South Africa and the United Arab Emirates.

On the face of it, ‘sin’ taxes such as these have three potential benefits. Either the higher cost of production is passed on to the consumer, who, deterred by the increased price of the soft drink, makes a healthier choice. Alternatively, to avoid paying the tax, companies can take steps to make their drinks healthier, a process known as reformulation. Finally, the tax may enable a government to bring in more revenue which can then be spent on fighting obesity, such as on school exercise programmes, although this only applies if reformulation does not take place.

It is fair to say the soda companies, publicly at least, do not see things the same way. But commercial opposition to the tax in Britain, while certainly present, has hardly been deafening. This may be because the crucial battle was fought, and arguably won, more than four years ago.

To understand just how deep and firm a grip soda companies, and particularly Coca-Cola, have over Mexico, you have to go there. Anywhere. Even in Chiapas, the most impoverished state in the land, villages comprising just a few hundred residents will normally support six or seven abarrotes, tiny convenience stores awkwardly emblazoned with the garish Coca-Cola livery, more often than not humming to the sound of a generator powering the prominent bright-red fridges with their ranks of glistening bottles.

The decaying mountain roads, devoid of any real traffic, nevertheless thunder as the company’s lorries sporting the slogan ‘Disfrutala!’ (‘Enjoy!’) churn their way up and down the hairpin bends to restock the agrarian communities. When one of them breaks down, its driver, 20-year-old Lorenzo Perez, squinting in the midday sun, explains he is on his way to visit a few of the aborrotes in his home town of Zinacantán. To keep even this handful of outlets in stock, it is a journey he must make two or three times a week.

Further into the Chiapas central highlands, in the village of Cruztón, Jose Jimemes, 47, slouches against one of the fridges in his store as he recounts how drinking habits in the region have changed. ‘Coke became really big around here in the ’80s, but even before that my mother would give me a bottle filled with it when I was a baby,’ he says. ‘People used to fill themselves up on pozol [a drink made from fermented corn dough] before they worked in the fields but they switched to Coke and drank it in the same way, thinking it would fill them up. Now people are becoming more aware that Coke has nothing good in it, but they’re still drinking it.’

In some of the remoter settlements, Coca-Cola has become almost a parallel currency, as Gerard Bravo, who runs a taco stand in Tenejapa town square, explains. ‘If you are going to ask a girl to marry you, you wouldn’t dream of going to her father’s house without a big crate of Coke. It’s the same if you need to raise an issue with one of the local authorities: bring Coke.’

In the town of Chamula, about 20 miles away through the hills, the role of Coca-Cola is taken somewhat further. From the outside, the Iglesia de San Juan looks like any other Latin America Catholic church. But to step inside is to confront a baffling three-way hybrid of iconography: statues of Christian saints, ancient Mayan mysticism and nods to US consumer culture. Identifying the plain-clothed ‘sacristans’, the people who look after the church, is not immediately obvious, until you work out what to look for. Hanging from each of their belts are not rosary beads or the chains of an incense-burning thurible, but bottle openers.

Depending on the type of cleansing required, a bunch of basil may be rubbed over the parishioner’s face to ward off evil spirits; the configuration of the candles – white to represent a corn-based offering to God, tallow for meat – may change; sometimes a chicken is slaughtered. But Coca-Cola always plays a part.

The shamans are cagey about why the drink is used. Maria Santis, 48, who learnt ‘healing’ at her mother’s knee, simply says with a twinkle in her eye: ‘Coke fixes everything.’

The situation in Chiapas is extreme: Coca-Cola operates a large bottling plant outside the main city of San Cristóbal de las Casas and has for many years been a very visible presence in the community. But it is a story repeated to varying degrees across Mexico, regardless of class, income or geography. The company is deeply woven into the fabric of everyday life and it has been common for schools to display anything from subtle logos to vast advertising murals, a legacy of cash-strapped head teachers eagerly taking up offers of ‘pro bono’ repairs to classrooms or basketball courts.

Also striking has been the attitude of significant parts of the medical establishment, which for years argued against coercive measures to tackle poor diet. When in 2013 president Enrique Peña Nieto took everyone by surprise by proposing a 10 per cent flat tax on sugary drinks, the measure was publicly opposed by Dr María Guadalupe Fabián San Miguel, the medical director of the Mexican Diabetes Federation, as well as by Dr Mercedes Juan López, the country’s then health secretary.

However, the tax was a product of Mexico’s finance ministry, where the soda industry enjoys less influence, and, to the astonishment of the international public health community, it became law in January 2014.

The attention of health officials around the world is now trained on Mexico – the fattest and most populous nation to have introduced such a tax – to find out whether it works. According to Dr Pablo Kuri-Morales, it will take years to gather the data to reliably answer that question. Nevertheless, in 2017 campaigners were encouraged by a joint study by the University of North Carolina and the Mexican National Institute of Public Health, which found there had been a 5.5 per cent drop in sugary-drink sales in the first year after the tax was introduced, followed by a 9.7 per cent decline in the second.

Sceptics have questioned the methodology and pointed out the research was funded by Bloomberg Philanthropies, which has long supported the introduction of fizzy drink taxes, although most scientists agree that, while imperfect, the data is the best available. The question is: to what extent do the results apply to Britain?

Professor Jack Winkler, who supports the Soft Drinks Industry Levy, points out that the ambition behind the two laws is fundamentally different. Mexico’s is a flat-rate tax designed to inhibit consumption, whereas the UK’s tiered tax – which anyway is roughly double the Mexican levy – is designed to stimulate reformulation.

As far as he is concerned, it is already having an effect. ‘On the face of it, in Britain the soft drinks industry behaved utterly like you’d expect them to: “Why are you singling out sugar? Why don’t you focus on exercise?” etc, etc. They were staunchly against it.

‘But behind the press releases, if you look at what they have done, there has been a sensational change, a triumph in terms of reformulation. Before the tax has even come in, we have got rid of a huge amount of the sugar in our drinks. If you look at Coca-Cola, the only product they’re going to have left that is subject to a full tax is Coke red, and that’s going to be sold in smaller portions.’

Last month, an Office of Budget Responsibility report – enthusiastically tweeted by George Osborne – found ‘producers are reformulating their drinks sooner and more aggressively than previously assumed’.

Even if our ‘sugar tax’ is, or already has been, successful according to its own terms, no one is suggesting that this alone will turn the tide of obesity. Rules banning the advertising of unhealthy products to children are in their infancy and will take vociferous maintenance and improvement to combat the slippery character of internet marketing.

Meanwhile, although the arguments may have been deployed cynically, the soft drinks companies are surely right: the effort should not be just about sugar; there should be a focus on exercise.

Ultimately, the battle can only be won if people understand the risks and make the right choices, so, yes, public information campaigns will continue. As the experience in Mexico is proving, it will be devilishly difficult to establish how well the tax is working in terms of its real goal, which is to improve the nation’s dietary health. When it comes to population-wide interventions, cause and effect is almost impossible to prove.

Professor Mike Rayner, a population health specialist at Oxford University, however, suggests watching out for the child tooth-extraction statistics as a possible early indicator of success. ‘Undoubtedly there has been an effect on reformulation going on as a result of the announcement of the tax,’ he says. ‘Whether that’s going to be big enough, we don’t really know.’

One point upon which most campaigners do agree is that sugar taxes have been successful in recasting brands like Coca-Cola in the public perception. When, last month, the company announced it would be stopping school visits to its ‘education centres’ in the UK, Richard Kemp, a senior Liverpool councillor who has campaigned against Coca-Cola promotions that appeal to children, likened the fizzy drinks industry to tobacco: legal, but no longer seen as a force for good. ‘They shouldn’t be working with children,’ he said. ‘It’s three decades since we stopped cigarette companies doing factory trips, and we are catching up with fizzy drinks.’ In the same vein, Coca-Cola’s promotional Christmas truck tour of Britain last year attracted plenty of criticism.

Perhaps the juggernaut is turning in Mexico, too. Up in the Chiapas highlands, Jose Jimemes is still enjoying a roaring trade selling Coca-Cola, but he won’t give it to his children. Back in Mexico City, Moises Sanchez has lost 12 pounds and his daughter, Merari, is dancing at regional level. ‘Thankfully I haven’t developed diabetes, and I am here [Tragones Anónimos] because I don’t want to have it,’ he says. ‘But,’ he adds, pointing to his mouth, ‘it’s a very difficult process to understand because we are given this software at childhood.’